Biomaterial Database

DRGs and hospital case records: implications for Medicare case mix accuracy. 1984

A N Johnson, and G L Appel

As Medicare moves to DRG-based prospective payment, it is not clear whether the federal government has adequate data upon which to formulate DRG prices and assess hospital case mix. This study compares the Medicare case mix of Minneapolis-St. Paul hospitals based on the historical information submitted for billing purposes on the Medicare claim with the actual case mix of hospitals as described in the medical record chart. It was found that for the same patients, the DRG based on the claim matched the DRG on the medical record approximately half of the time. These "mismatches" resulted in a statistically significant understatement of hospitals' case mix, and have obvious implications for the setting of DRG prices and equitable hospital reimbursement.

UI	MeSH Term	Description	Entries
D007341	Insurance	Coverage by contract whereby one part indemnifies or guarantees another against loss by a specified contingency.	Indemnity,Insurance Premiums,Insurance Premium,Premium, Insurance,Premiums, Insurance
D007344	Insurance Claim Reporting	The design, completion, and filing of forms with the insurer.	Claim Reporting, Insurance,Reporting, Insurance Claim
D008499	Medical Records	Recording of pertinent information concerning patient's illness or illnesses.	Health Diaries,Medical Transcription,Records, Medical,Transcription, Medical,Diaries, Health,Diary, Health,Health Diary,Medical Record,Medical Transcriptions,Record, Medical,Transcriptions, Medical
D008910	Minnesota	State bordered on the north by Canada, on the east by Lake Superior and Wisconsin, on the south by Iowa, and on the west by North Dakota and South Dakota.
D011445	Prospective Payment System	A system wherein reimbursement rates are set, for a given period of time, prior to the circumstances giving rise to actual reimbursement claims.	Discretionary Adjustment Factor,Prospective Pricing,Prospective Reimbursement,Reimbursement, Prospective,Adjustment, Discretionary,Adjustment Factor, Discretionary,Adjustment Factors, Discretionary,Adjustments, Discretionary,Discretionary Adjustment,Discretionary Adjustment Factors,Discretionary Adjustments,Factor, Discretionary Adjustment,Factors, Discretionary Adjustment,Payment System, Prospective,Payment Systems, Prospective,Pricing, Prospective,Prospective Payment Systems,Prospective Reimbursements,Reimbursements, Prospective,System, Prospective Payment,Systems, Prospective Payment
D003365	Costs and Cost Analysis	Absolute, comparative, or differential costs pertaining to services, institutions, resources, etc., or the analysis and study of these costs.	Affordability,Analysis, Cost,Cost,Cost Analysis,Cost Comparison,Cost Measures,Cost-Minimization Analysis,Costs and Cost Analyses,Costs, Cost Analysis,Pricing,Affordabilities,Analyses, Cost,Analyses, Cost-Minimization,Analysis, Cost-Minimization,Comparison, Cost,Comparisons, Cost,Cost Analyses,Cost Comparisons,Cost Measure,Cost Minimization Analysis,Cost, Cost Analysis,Cost-Minimization Analyses,Costs,Measure, Cost,Measures, Cost
D003953	Diagnosis-Related Groups	A system for classifying patient care by relating common characteristics such as diagnosis, treatment, and age to an expected consumption of hospital resources and length of stay. Its purpose is to provide a framework for specifying case mix and to reduce hospital costs and reimbursements and it forms the cornerstone of the prospective payment system.	Case Mix,DRG,Diagnosis Related Group,Diagnosis-Related Group,Case Mixes,DRGs,Diagnostic-Related Group,Group, Diagnostic-Related,Groups, Diagnostic-Related,Diagnosis Related Groups,Diagnostic Related Group,Diagnostic-Related Groups,Group, Diagnosis Related,Group, Diagnosis-Related,Group, Diagnostic Related,Groups, Diagnosis Related,Groups, Diagnosis-Related,Groups, Diagnostic Related,Related Group, Diagnosis,Related Groups, Diagnosis
D006278	Medicare	Federal program, created by Public Law 89-97, Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits to persons over the age of 65 and others eligible for Social Security benefits. It consists of two separate but coordinated programs: hospital insurance (MEDICARE PART A) and supplementary medical insurance (MEDICARE PART B). (Hospital Administration Terminology, AHA, 2d ed and A Discursive Dictionary of Health Care, US House of Representatives, 1976)	Health Insurance for Aged and Disabled, Title 18,Insurance, Health, for Aged and Disabled,Health Insurance for Aged, Disabled, Title 18,Health Insurance for Aged, Title 18
D006291	Health Policy	Decisions, usually developed by government policymakers, for determining present and future objectives pertaining to the health care system.	Health Care Policies,Health Policies,Healthcare Policy,National Health Policy,Care Policies, Health,Health Care Policy,Health Policy, National,Healthcare Policies,National Health Policies,Policies, Health,Policies, Health Care,Policies, Healthcare,Policy, Health,Policy, Health Care,Policy, Healthcare
D014481	United States	A country in NORTH AMERICA between CANADA and MEXICO.